Keeping systolic <120 or at least <130 is the goal for BP control. If medication is required, how much above these systolic goals do we tolerate if reaching the goal requires diastolic being pushed to the 50s. Some write about the J-curve and the increase in cardiac events with diastolic below 60 or 55.
e.g., I am on an ARB, and with lifestyle and adjusting the ARB dose can easily get my SBP <120 but at the cost of my DBP<55. Symptoms are not worrisome (just some occasional orthostatic lightheadedness wo/falls), but I am concerned about the J-curve and is the low diastolic cost to getting an ideal systolic worth it in terms of cardiac events (75yo male)
Most of the articles I read in Medpage still focus on lowering dietary sodium intake only, with no mention of potassium. IMO, this is not very useful, as people are not compliant when not in a study (and sometimes not even when they ARE in a study). The US FDA is considering a proposal to allow salt substitutes with potassium to be added to foods by manufacturers, but there are some advocates who say this will cause harm to people with CKD (link #1). According to the second link, potassium might be more helpful to those in the earlier stages of CKD, but not helpful and maybe even harmful to those in the later stages. Given how common CKD is in diabetes, and some do not even know they have it, it seems like this is a caution that doctors should tell their patients about, and test for hyperkalemia if a potassium added salt substitute is used. More research is needed to determine whether salt substitutes for those with CKD are recommended or not, with perhaps refinement of which stage of CKD.
Keeping systolic <120 or at least <130 is the goal for BP control. If medication is required, how much above these systolic goals do we tolerate if reaching the goal requires diastolic being pushed to the 50s. Some write about the J-curve and the increase in cardiac events with diastolic below 60 or 55.
e.g., I am on an ARB, and with lifestyle and adjusting the ARB dose can easily get my SBP <120 but at the cost of my DBP<55. Symptoms are not worrisome (just some occasional orthostatic lightheadedness wo/falls), but I am concerned about the J-curve and is the low diastolic cost to getting an ideal systolic worth it in terms of cardiac events (75yo male)
Why are you less stringent with your older patients?
Most of the articles I read in Medpage still focus on lowering dietary sodium intake only, with no mention of potassium. IMO, this is not very useful, as people are not compliant when not in a study (and sometimes not even when they ARE in a study). The US FDA is considering a proposal to allow salt substitutes with potassium to be added to foods by manufacturers, but there are some advocates who say this will cause harm to people with CKD (link #1). According to the second link, potassium might be more helpful to those in the earlier stages of CKD, but not helpful and maybe even harmful to those in the later stages. Given how common CKD is in diabetes, and some do not even know they have it, it seems like this is a caution that doctors should tell their patients about, and test for hyperkalemia if a potassium added salt substitute is used. More research is needed to determine whether salt substitutes for those with CKD are recommended or not, with perhaps refinement of which stage of CKD.
https://www.statnews.com/2023/08/15/patient-advocates-warn-fda-proposal-on-salt-intake-kidney-disease/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9395506/
Can't argue with that!